Provider Demographics
NPI:1972292928
Name:AVALOS, JESUS ENRIQUE
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:ENRIQUE
Last Name:AVALOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1426 E CONSTANCE WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6716
Mailing Address - Country:US
Mailing Address - Phone:623-302-8352
Mailing Address - Fax:
Practice Address - Street 1:1426 E CONSTANCE WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6716
Practice Address - Country:US
Practice Address - Phone:623-302-8352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-25788225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist